Scleral Lenses ALEX D GIBBERMAN, O.D. HARPERS POINT EYE ASSOCIATES

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1 Scleral Lenses ALEX D GIBBERMAN, O.D. HARPERS POINT EYE ASSOCIATES

2 Overview/goals today Basic concepts Fitting technique/criteria Insertion, removal, flat vs steep, evaluation, lens care, Troubleshooting How to implement into my office

3 Scleral Lenses Definition: A large gas permeable contact lens that rests fully BEYOND the limbus and may generally range from mm in diameter Material: optimum extra or optimum extreme (dk 100 and 125)

4 Definitions Corneo-scleral lens: 13-15mm Fenestrated (more similar to a soft lens fit) Non fenestrated (more similar to a scleral fit) Mini sclerals 15-18mm Still entirely vaults cornea 100% of my fits have been this type Full scleral Greater than 18mm Megalocornea, very prominent corneal grafts, the most advanced cone

5 Who benefits? ABNORMAL EYES NORMAL EYES Keratoconus/pellucid High ammetropia/cylinder Post surgical Moderate/Severe Dry Eye Disease Transplant, RK, LASIK Presbyopia Corneal scarring smaller eyes/corneas Salzmann s degeneration

6 What do I need to get Started Fitting Set DMV plunger BIG and SMALL Cut off bottom of big plunger Boxes of inhalation 0.9% non preserved saline Fluorescein Strips Water proof Apron Boston simplus (optional) Optional but helpful OCT (ant seg capable),topographer

7 NOW WE ARE READY TO FIT! Not have a fit..

8 Step 1:Setup a Work Station

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10 Step 2: Insertion Select a trial lens to start with (steep eye, steep lens, flat eye, flat lens)

11 Step 2: Insertion Select a trial lens to start with (steep eye, steep lens, flat eye, flat lens) Have patient put on apron Place lens on BIG plunger, fill until saline is overflowing Dip fluorescein strip into the saline filled contact lens Have patient place their chin against their chest and have them place their head parallel to the ground Have the patient stare toward the ground while they grab their LOWER LID. You as the doctor will grab their UPPER LID Quickly insert the scleral lens trying to lose as little fluid as possible quick and steady helps prevent bubbles

12 Step 3: Evaluation Using BRIGHT, WHITE light, create an optic section and move the light source to 45 degrees Evaluate the central clearance or the clearance over the STEEPEST point of the cornea. It should be at or near 250um. Move the slit beam toward the limbus. There should still be at least a sliver of green light still visible as you cross over it into the sclera. If not, increase limbal clearance or get a larger diameter lens Make sure the edges of the lens are not compressing or impinging blood vessels and that they are no lifting up. Should fit like a glove!

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14 If the glove don t fit Get a new glove

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16 Limbal Clearance

17 What to Record during initial fit Type of lens used (Acculens Maxim, zen lens custom stable, etc Base curve, diameter (all listed on each trial lens) The over refraction with vision Each lens has an inherent power so just record the over refraction) HIGHLY recommend checking TORIC over refraction Comment on central clearance, limbal clearance, and edges Any changes you want made Ideal fit has 250um clearance initially, is well centered with no edge impingement and is well aligned with the sclera and minimal movement

18 Example OD Maxim 7.34/15.9 OR x 85 20/20-350um central, mild low sitting lens, edges mildly steep, impingement of PING nasally For this lens I would request to decrease central clearance ~75um which would likely take care of the edges and help center the lens. I would also add double slab off which is a lens design that helps centration.i would also add a notch nasally to circumvent the pinguecula which I will show an example of later. Finally I would incorporate a front toric to the lens which takes care of th residual cylinder. A black dot would be placed at 6 o clock which is how we want the patient to insert the lens.

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21 Corneal Grafts Must vault the entire graft and edge of the transplant zone!

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24 Impingement

25 Technology OCT Once lens is on the eye can use pachymetry function to measure vault and the angle function to evaluate lens edges and limbus. Topography Accurate measure of corneal diameter Better identify irregular corneas and steepest areas to ensure proper vaulting Central corneal apex (w/in central 4mm) go with standard design More peripheral corneal apex or peripheral abnormalities, go with reverse geometry design Transplants, Salzmann s

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29 3 steps to a good scleral fit 250 microns of central clearance (or over steepest point on cornea) Adequate limbal clearance (at least 50um) Aligned edges No compression (not enough limbal) No impingement (too steep) No edge lift (too flat)

30 Billing

31 DISCLAIMER 1. The SHERMAN ANTITRUST ACT says we, sitting here as a group of competitors (strike 1 and 2), can NOT discuss setting fees! The fees here discussed are intended to be instructional only. 2. That being said here is my fee recommendation

32 Costs Fitting set Ballpark $400 per set (differs company to company) Cost of lenses (plus shipping) Ballpark of $400-$450 for OD and OS total Base lens price + extras (slab off, front toric, plasma, inverse, etc) Different companies, different remake policies Chairtime!!!! Box of saline (100 vials) ~ $15 Plungers: Small: pack of 3 ~ $10 Large: pack of 3 ~ $15

33 Reimbursements Medical insurancepain in the A** 92014, 92015, V2531 (scleral CL) H (stable K conus) Also needed a medical necessity letter and chart notes STICK TO BILLING THE VISION PLANS!!!!!!!!!!! Vision plans (VSP, Eyemed, Davis) $$$$$$$$$$ Diagnosis Keratoconus, corneal ectasia, vision improvement up to $ fit+lenses High ammetropiavariable reimbursement

34 CPT Codes fitting of CL for keratoconus Need interpretation/report for these refraction 92310: fitting of RGP sphere OU 92312: OCT ant seg 92313: fitting of corneoscleral lens 92285: ext ocular photo 92286: specular 76514: pachymetry 92499: aberrometry 92025: topography These are reported IN ADDITION to your 92014, 92012, 99212, Do NOT use for K conus 92326: replacement of contact lens Used if 1 year visit and simply ordering new set without making any substantial changes If making changes, use the

35 Material Codes V2531-right and left Scleral lens codes V2599 Hybrid lens code Often requires letter of medical necessity V2627 Scleral Shell Code Controversial but can use for severe dry eye in combination with failed alternatvies

36 VSP Step 1: call VSP to see if patient eligible for medically necessary lenses Step 2: get authorization number from VSP to enter into eyefinity and follow the claim instructions from there. V2531 = scleral gas perm lens V2599 = contact lens, other type Hybrid lens code only = fitting of corneo-scleral lens = fitting of CL for keratoconus Easiest ways to get VSP medically necessary approval Keratoconus Ammetropia > +/ D Corneal ectasia +peripheral corneal degeneration Eyemed Step 1: Call Eyemed and find out if patient is eligible Step2: get authorization number Step 3: print out Eyemed Form, fill it out and fax it in. Use 92 code (92072) V code listed on bottom of form. Keratoconus Must specify mild/moderate vs advanced Advanced pays up to 2300 Mild/mod pays up to 1200 High ammetropia Corneal ectasia Anisometropia

37 example Keratoconus: comp visit, existing patient Existing comp exam Topography External photo if scarring or striae or neo etc: Refraction (can use -22 modifier for complex)-pays extra Requires letter of med necessity to insurance plan Pachymetry This portion goes to medical (other than refraction) Generally will return for fit Fitting of contact lens for keratoconus Code can only be used for initial fit. Subsequent fits must use other evaluation of contact lens code such as 92313*** Can be broken down into OD and OS or combined as one fit fee Scleral materials code V2531-right V2531-left 1 week CL check included in this. ALL SUBSEQUENT VISITS are BILLED medical visits once finalized!

38 VSP vs EYEMED from previous example VSP: use V2531 right and left for sclerals Must specifically type exact brand name of lens use in Box 19 eyefinity If you just write scleral and Acculens, they will default to easyfit and you will get paid a LOT less VSP maximum = $2300 for med nec scleral for eyemed simply fill out the form correctly Mild k conus: steep K < 53 and pachy of >475, mild symptoms Reimburses up to $1200 Advanced: steep k >53 pachy <475 or any scarring, worse VA Reimburses up to $2500

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40 Reimbursements VSP Keratoconus$2300 max Corneal ectasia$2300 High ammetropia$800ish Eyemed Vision improvement$2300 Advanced keratoconus2300 Early Keratoconus1200 High Ammetropia700 Corneal Ectasia2300 Anisometropia700 Superior Requires letter of med necessity +chart notes Davis Requires chart notes + letter of medical necessity Caresource/Medicaid Keratoconus or Corneal EctasiaTBD Requires chart notes + letter of medical necessity

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42 Choose Your Fee Schedule Accordingly Things to consider Consulting visit Chair time Fitting Dispense Follow Cost of goods Plungers Fluorescein Fit set saline

43 Appointments Visit 1: consult, topography, pachymetry, refraction 15 minutes This is usually a billed medical visit if patient was referred. Visit 2: The fit 30-45min Visit3: Dispense, Insertion/removal training 30-45min Follow up 1 week CL check Every few months for transplant patients. Every 6 months for everyone else

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45 QUESTIONS Does a scleral lens stop Keratoconus from progressing? What happens if my prescription shifts or changes? How long do the lenses last if my prescription doesn t change? Can I get cross linking before or after being fit? Can I use allergy drops (or any drops) with the lenses?

46 Scleral Case 1 36 year old female, keratoconus OS>OD Previously wore soft lenses Best spec Rx: OD 20/30- OS 20/100 Corneal Striae OU, scarring OS Pachs: OD 470um OS 403um

47 OCT Image of Scleral OS

48 With Sclerals OD 20/30+ OS 20/30 (improved from 20/100) Happy patient

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51 THANK YOU!!!!! REMEMBER PRACTICE MAKES PERFECT DON T GET FRUSTRATED MISTAKES WILL HAPPEN TAKE ADVANTAGE OF CONSULTING CALL ME MAYBE MOST IMPORTANT LOOK AT YOUR OWN PATIENT BASE MARKET YOURSELF TO OPHTHALMOLOGY OR SURROUNDING DOCS